Study: Care standards after hospital discharge lowered some rehospitalizations 

A new study published last week in The Journal of Post-Acute and Long-Term Care Medicine found that standardized care protocols in place at skilled nursing facilities improve hospital readmission rates.

The team looked specifically at readmission rates for people with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after they were discharged to skilled nursing facilities. Authors compared the rates of people readmitted to the hospital 30 days after being discharged. They studied people the year before care protocols were introduced and two years after the protocols were enacted. There were separate protocols for COPD and CHF.

The protocols consisted of medical provider or nurse assessments on admission to nursing facilities. The protocols also included multidisciplinary care planning, as well as medication management strategies. 

Researchers examined 1,128 people who were in hospitals the year before the protocols were put into action. They also evaluated data on 2,297 people in hospitals and discharged to nursing facilities after the protocols began taking effect. About half of them had CHF without COPD and had the standardized protocol; 47% with COPD who didn’t have CHF also had the standardized protocol in effect. Of those with COPD and congestive heart failure, 49% had protocols in play.

Of people with the COPD protocol, readmission fell from 23.5% in 2011 to 12.1% in 2015. There were fluctuations for people on the CHF protocol. Overall, when people were exposed to standardized care protocols in the nursing facilities, there were improvements in readmission rates, the authors said.

“Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems,” they wrote in the report. “Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions.”

The authors say that partnerships between hospitals and skilled nursing facilities can ease transitions in care and prevent unneeded readmissions. A key factor is having a nursing educator train nursing facility staff on the protocol and working with them to monitor people and track how well they stick to protocol, the authors noted.